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Flashcards in Mini-Cases Deck (180)
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1

21 yo F presents with several episodes of throbbing left temporal pain that last for 2 to 3 hours. Before onset, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. Her headaches are often associated with nausea and vomiting and she feels bothered by light. She has a family history of migraine.

Differentials:

  • Hemiplegic Migraine (migraine with motor aura)
  • Tension Headache
  • Cluster Headache
  • TIA
  • Partial Seizure
  • Pseudotumor Cerebri
  • CNS Vasculitis
  • Focal Seizure (occipito-parietal)
  • Intracranial Neoplasm

 

Diagnostics:

  • MRI-brain
  • CT-head
  • CBC
  • ESR

2

26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.

Differentials:

  • Cluster Headache
  • Migraine
  • Trigeminal Neuralgia
  • Intracranial Neoplasm
  • Tension Headache

 

Diagnostics:

  • MRI-brain
  • CT-head
  • CBC
  • ESR

3

65 yo F presents with a new-onset severe, intermittent right temporal headache, fever, blurred vision in her right eye, weight loss, and pain in her jaw when chewing. She has a history of shoulder stiffuess. On examination she has right temporal tenderness to palpation and reduced right eye visual acuity.

Differentials:

  • Temporal Arteritis (Giant Cell Arteritis)
  • Vasculitis
  • Migraine
  • Cerebral Abscess
  • Cluster Headache
  • Tension Headache
  • Meningitis
  • Carotid Artery Dissection
  • Pseudotumor Cerebri
  • Trigeminal Neuralgia
  • Intracranial Neoplasm
  • Temporomandibular Joint (TMJ) Disorder

 

Diagnostics:

  • Temporal Artery Biopsy
  • ESR
  • CRP
  • CBC
  • Doppler U/S-carotid
  • MRI-brain

4

30 yo F presents with 1 week of frontal headache, fever, and nasal discharge, the headache worsens when she bends forward. There is pain on palpation of the frontal and maxillary sinuses. She has a history of allergies.

Differentials:

  • Acute Sinusitis
  • Migraine
  • Tension Headache
  • Cerebral Abscess
  • Meningitis
  • Intracranial Neoplasm

 

Diagnostics:

  • CBC
  • XR-sinus
  • CT-sinus

5

50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3 to 4 times a week, typically toward the end of her workday. She is experiencing significant stress in her life and recently decreased her intake of caffeine. Neurological examination is normal.

Differentials:

  • Tension Headache
  • Migraine
  • Caffeine or Analgesic Withdrawal
  • Depression
  • Intracranial Neoplasm
  • Cluster Headache
  • Pseudotumor Cerebri

 

Diagnostics:

  • CBC
  • Electrolytes
  • ESR
  • MRI-brain
  • LP-CSF analysis
  • MRI-brain

6

35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.

Differentials:

  • Subarachnoid Hemorrhage
  • Meningitis/Encephalitis
  • Intracranial Hemorrhage
  • Vertebral Artery Dissection
  • Intracranial Venous Thrombosis
  • Migraine
  • Hypertensive Encephalopathy
  • Intracranial Neoplasm

 

Diagnostics:

  • CT-head without contrast
  • LP-opening pressure and CSF analysis
  • CBC
  • PT/PTT/INR
  • Urine Toxicology
  • Digital Subtraction Angiography (DSA)
  • MRI-brain
  • CT-angiography

7

25 yo M army recruit presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity.

Differentials:

  • Meningitis
  • Subarachnoid Hemorrhage
  • Encephalitis
  • Sinusitis
  • Migraine
  • Intracranial or Epidural Abscess

 

Diagnostics:

  • LP-CSF analysis (cell count, protein, glucose, Gram stain, PCR for specific pathogens, culture)
  • Blood Culture
  • CBC
  • CT-head
  • MRI-brain
  • PT/PTT/INR

8

18 yo obese F presents with a daily pulsatile headache, vomiting, and blurred vision for the past 2 to 3 weeks. She is taking OCPs.

Differentials:

  • Pseudotumor Cerebri
  • Migraine
  • Tension Headache
  • Intracranial Venous Thrombosis
  • Intracranial Neoplasm
  • Cluster Headache
  • Meningitis

 

Diagnostics:

  • Urine hCG
  • LP-opening pressure and CSF analysis
  • Dilated Fundoscopy Examination
  • Funduscopic Eye Exam
  • MRI-brain
  • Visual Field Testing

9

57 yo M c/o daily pain in the right cheek for the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 1 to 2 minutes.

Differentials:

  • Trigeminal Neuralgia
  • Tension Headache
  • Migraine
  • Cluster Headache
  • TMJ Disorder
  • Temporal Arteritis
  • Intracranial Neoplasm

 

Diagnostics:

  • MRI-brain
  • CBC
  • ESR

10

81 yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has worsened after each stroke (stepwise decline in cognitive function).

Differentials:

  • Vascular ("multi-infarct") Dementia
  • Alzheimer Disease
  • Normal Pressure Hydrocephalus
  • Chronic Subdural Hematoma
  • Intracranial Neoplasm
  • Depression
  • B12 Deficiency
  • Neurosyphilis
  • Hypothyroidism

 

Diagnostics:

  • CBC
  • VDRL/RPR
  • Serum B12
  • TSH
  • MRI-brain
  • CT-head
  • LP-CSF analysis

11

84 yo F brought by her son c/o forgetfulness (forgets phone numbers, loses her way back home) and difficulty performing some of her daily activities (bath· ing, dressing, managing money, using the phone). The problem has progressed gradually over the past few years.

Differentials:

  • Alzheimer Disease
  • Vascular Dementia
  • Depression
  • Hypothyroidism
  • Chronic Subdural Hematoma
  • Normal Pressure Hydrocephalus
  • Intracranial Neoplasm
  • B12 Deficiency
  • Neurosyphilis

 

Diagnostics:

  • CBC
  • VDRL/RPR
  • Serum B12
  • TSH
  • MRI-brain
  • CT-head
  • LP-CSF analysis

12

72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months.

Differentials:

  • Normal Pressure Hydrocephalus
  • Alzheimer Disease
  • Vascular Dementia
  • Chronic Subdural Hematoma
  • Intracranial Neoplasm
  • Depression
  • B12 Deficiency
  • Neurosyphilis
  • Hypothyroidism

 

Diagnostics:

  • CT-head
  • MRI-brain
  • LP-opening pressure and CSF analysis
  • Serum B12
  • VDRL/RPR
  • TSH

13

55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past 2 months. His symptoms are associated with myoclonus, ataxia, and a startle response.

Differentials:

  • Creutzfeldt·Jakob Disease
  • Vascular Dementia
  • Lewy Body Dementia
  • Wernicke Encephalopathy
  • Normal Pressure Hydrocephalus
  • Chronic Subdural Hematoma
  • Intracranial Neoplasm
  • Depression
  • Delirium
  • B12 Deficiency
  • Neurosyphilis

 

Diagnostics:

  • CBC
  • Electrolytes, Calcium
  • Serum B12
  • VDRL/RPR
  • MRI-brain (preferred)
  • CT-head
  • EEG
  • LP-CSF analysis
  • Brain Biopsy

14

70 yo insulin·dependent diabetic M presents with episodes of confusion, dizziness, palpitations, diaphoresis, and weakness.

Differentials:

  • Hypoglycemia
  • Transient Ischemic Attack
  • Arrhythmia
  • Delirium
  • Angina
  • Medication·Induced

 

Diagnostics:

  • Glucose
  • CBC
  • Electrolytes
  • TSH
  • CPK·MB, Troponin
  • Echocardiography
  • ECG
  • MRI-brain
  • Doppler U/S-carotid
  • Urine Toxicology

15

55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for 2 minutes.

Differentials:

  • Subdural Hematoma
  • SIADH (causing hyponatremia)
  • Creutzfeldt-Jakob Disease
  • Intracranial Neoplasm
  • CNS Infection (eg. encephalitis)

 

Diagnostics:

  • CT-head
  • CBC
  • Electrolytes
  • TSH
  • MRI-brain
  • LP-CSF analysis

16

73 yo M presents with acute loss of vision in his left eye, palpitations, and shortness of breath. He has a history of atrial fibrillation and cataracts in his right eye. He has no eye pain, discharge, redness, or photophobia. He has not experienced headache, weakness, or numbness.

Differentials:

  • Retinal Artery Occlusion
  • Retinal Vein Occlusion
  • Acute Angle-Closure Glaucoma
  • Retinal Detachment
  • Temporal Arteritis (Giant Cell Arteritis)

 

Diagnostics:

  • Fluorescein Angiogram
  • Echocardiography
  • Doppler U/S-carotid
  • Intraocular Tonometry
  • ESR, CRP
  • Temporal Artery Biopsy
  • CBC

17

68 yo M presents with a 2-month history of crying spells, excessive sleep, poor hygiene, and a 15 lb (6.8 kg) weight loss, all following his wife's death. He cannot enjoy time with his grandchildren and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.

Differentials:

  • Normal Bereavement
  • Adjustment Disorder with Depressed Mood
  • Major Depressive Disorder
  • Schizoaffective Disorder
  • Depressive Disorder (not otherwise specified)

 

Diagnostics:

  • TSH
  • CBC
  • Urine Toxicology
  • Beck Depression Inventory
  • PHQ-9
  • QIDS-SR16

18

42 yo F presents with a 4-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered five similar episodes in the past, the first in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.

Differentials:

  • Major Depressive Disorder
  • Substance-Induced Mood Disorder
  • Persistent Depressive Disorder (Dysthymia)

 

Diagnostics:

  • Beck Depression Inventory
  • PHQ-9
  • QIDS-SR16
  • Blood Alcohol Level
  • TSH
  • CBC
  • Urine Toxicology

19

26 yo F presents with a 6.5 lb (2.9 kg) weight loss in the past 2 months, accompanied by early morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately 6 months before her presentation.

Differentials:

  • Bipolar I Disorder
  • Bipolar II Disorder
  • Cyclothymic Disorder
  • Major Depressive Disorder
  • Schizoaffective Disorder

 

Diagnostics:

  • Mood Disorder Questionnaire
  • Urine Toxicology
  • TSH
  • CBC

20

19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. He stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to "guard against the evil empire."

Differentials:

  • Schizophrenia
  • Schizoid or Schizotypal Personality Disorder
  • Schizophreniform Disorder
  • Psychotic Disorder due to a General Medical Condition
  • Substance-Induced Psychosis
  • Depression with Psychotic Features

 

Diagnostics:

  • Mental Status Exam
  • Urine Toxicology
  • TSH
  • CBC
  • Electrolytes

21

28 yo F c/o seeing bugs crawling on her bed for the past 2 days and hearing loud voices when she is alone in her room. She has never experienced anything similar in the past. She recently ingested an unknown substance.

Differentials:

  • Substance-Induced Psychosis
  • Brief Psychotic Disorder
  • Schizophreniforn Disorder
  • Schizophrenia
  • Psychotic Disorder due to a General Medical Condition

 

Diagnostics:

  • Urine Toxicology
  • Mental Status Exam
  • TSH
  • CBC
  • Electrolytes, BUN/Cr
  • AST/ALT

22

48 yo F presents with a 1 -week history of auditory hallucinations that state, "I am worthless" and "I should kill myself." She also reports a 2-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.

Differentials:

  • Schizoaffective Disorder
  • Mood Disorder with Psychotic Features
  • Schizophrenia
  • Schizophreniform Disorder
  • Psychotic Disorder due to a General Medical Condition

 

Diagnostics:

  • Mental Status Exam
  • Beck Depression Inventory
  • Urine Toxicology
  • TSH
  • CBC
  • Electrolytes

23

35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss within the past week. Examination is normal.

Differentials:

  • Meniere Disease
  • Benign Positional Vertigo
  • Labyrinthitis
  • Vestibular Neuronitis
  • Acoustic Neuroma

 

Diagnostics:

  • Dix-Hallpike Maneuver
  • Audiometry
  • Electronystagmography
  • CBC
  • VDRL/RPR (syphilis is a cause of Meniere disease)
  • MRI-brain

24

55 yo F c/o dizziness for the past day upon standing. She feels faint and has severe diarrhea that started 2 days ago. She takes furosemide for hypertension. On examination, she feels dizzy upon standing.

Differentials:

  • Orthostatic Hypotension due to Dehydration (diarrhea, diuretic use)
  • Vertebrobasilar Insufficiency
  • Cardiac Arrhythmias
  • Vestibular Neuronitis
  • Labyrinthitis
  • Benign Positional Vertigo

 

Diagnostics:

  • Orthostatic VS
  • Rectal Examination
  • CBC
  • Urea, Electrolytes
  • ECG
  • Stool for Occult Blood
  • Stool Leukocytes

25

65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on furosemide 2 days ago.

Differentials:

  • Drug-Induced Orthostatic Hypotension
  • Furosemide Ototoxicity
  • Vertebrobasilar Insufficiency
  • Vestibular Neuronitis
  • Labyrinthitis
  • Benign Positional Vertigo
  • Brain Stem or Cerebellar Tumor

 

Diagnostics:

  • Orthostatic VS
  • CBC
  • Urea, Electrolytes
  • ECG
  • Echocardiography
  • MRI-brain

26

44 yo F c/o episodes of dizziness on moving her head to the left. She feels that the room is spinning around her head. Dix-Hallpike maneuver reproduces the symptoms and elicits nystagmus.

Differentials:

  • Benign Positional Vertigo
  • Meniere Disease
  • Vestibular Neuronitis
  • Labyrinthitis
  • Acoustic Neuroma

 

Diagnostics:

  • Audiometry
  • Electronystagmograph
  • MRI-brain

27

55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI 2 days ago and has experienced no hearing loss or tinnitus.

Differentials:

  • Vestibular Neuronitis
  • Labyrinthitis
  • Benign Positional Vertigo
  • Meniere Disease
  • Vertebrobasilar Stroke/TIA

 

Diagnostics:

  • Audiogram
  • Electronystagmography
  • CT-head
  • MRI/MRA-brain

28

55 yo F c/o dizziness that started this morning and of "not hearing well." She feels nauseated and has vomited once in the past day. She had a URI 2 days ago.

Differentials:

  • Labyrinthitis
  • Vestibular Neuronitis
  • Meniere Disease
  • Acoustic Neuroma
  • Vertebrobasilar Stroke/TIA

 

Diagnostics:

  • Audiogram
  • Electronystagmography
  • CT-head
  • MRI/MRA-brain

29

26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused after regaining consciousness (as witnessed by his colleagues).

Differentials:

  • Generalized Tonic-Clonic Seizure
  • Convulsive Syncope
  • Substance Abuse/Overdose
  • Malingering
  • Hypoglycemia

 

Diagnostics:

  • CBC
  • Electrolytes, Glucose
  • Urine Toxicology
  • EEG
  • MRI-brain
  • CT-head
  • LP-CSF analysis
  • ECG

30

55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient loss of consciousness. His past medical history is significant for hypertension and diabetes mellitus.

Differentials:

  • Drug-Induced Orthostatic Hypotension (causing syncope)
  • Hypoglycemia
  • Cardiac Arrhythmia
  • Syncope (vasovagal, other causes)
  • Stroke
  • MI
  • Pulmonary Embolism

 

Diagnostics:

  • Orthostatic VS
  • CBC
  • Electrolytes, Glucose
  • Echocardiography
  • CT-head
  • ECG
  • V/Q Scan
  • CTA-chest with IV contrast
  • D-dimer